APPLICATION BY SURVIVING OWNER

OF A WATER SHARE

Section 84L Water Act 1989

Lodged by -

Name:

Address:

Customer ID:

Customer Own Ref:

Privacy Collection Statement

The information from this form is collected under the Water Act 1989, in order to process this transaction. The information is used for the purpose of maintaining the water register and for the provision of statistical water market information. Most of the information in the water register is available to the public. Incomplete forms cannot be processed.

The applicant applies to be recorded as owner of the water share described owned jointly with the deceased.

Water Share Identification No.:

Applicant: (full name of surviving joint owner)

Address of Applicant: (full address including postcode)

Deceased Owner of Water Share: (full name of deceased joint owner)

Dated:

Execution by Applicant

I certify that the Applicant, with whom I am personally acquainted or as to Certified correct for the purposes of the Water Act 1989

whose identity I am otherwise satisfied, signed this document in my presence. by the Applicant.

Signature of witness:…………………………………………

Name of witness:…………………………………………….. Signature of Applicant:

or

Certified correct for the purposes of the Water Act 1989

Signature of Australian Legal Practitioner under the Legal Profession Act 2004 for the Applicant:

Approved Form No: WR-05SVR

VICTORIAN WATER REGISTER, 570 Bourke Street, Melbourne 3000 Telephone: (03) 8636 2010

The back of this form must not be used.


I

of

Do solemnly and sincerely declare that-

1. died on

2. The deceased was one of the joint owners of -

Water Share Identification No.:

3. My means of knowledge for making the above statements are-

I solemnly and sincerely declare that this declaration is signed with my name and handwriting, I acknowledge that this declaration is true and correct in every particular and I make it in the belief that a person making a false declaration is liable to the penalties of perjury.

Declared at

in the State of Victoria,

the day of 20

before me (signature of declarant)

Signature of witness

Print name in full

Address

Qualification

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